SEQUOIA SPRINGS SENIOR LIVING COMMUNITY

Official classification

Type A

Official code

87465(a)(4)

Regulation authority

CCR

What the official deficiency says

87465 Incidental Medical and Dental Care:(4) The licensee shall assist residents with self administered medications as needed. This requirement is not met as evidenced by: Based on records reviewed, Licensee did not ensure resident received assistance with medication as ordered. This poses an Immediate Health, Safety or Personal Rights risk to residents in care. This is a repeat violation within a 12 month period. An immediate civil penalty of $250 is being issued today.

Official plan of correction

Staff have been retrained. POC cleared during visit.

Deadline recorded: Jul 31, 2026. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87465(a)(4)

Regulation authority

CCR

What the official deficiency says

87465 Incidental Medical and Dental Care:(4) The licensee shall assist residents with self-administered medications as needed. This requirement is not met as evidenced by: Based on records reviewed, Licensee did not ensure resident received assistance with medication as ordered. This poses an Immediate Health, Safety or Personal Rights risk to residents in care.

Official plan of correction

Licensee agrees to schedule refresher training for medication staff and submit date of training to CCL by 05/14/2026. Self certifiation of completed training shall be submitted to CCL by 06/12/2026.

Deadline recorded: May 14, 2026. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

1569.625(b)(2)

Regulation authority

HSC

What the official deficiency says

(2) In addition to paragraph (1), training requirements shall also include an additional 20 hours annually, eight hours of which shall be dementia care training, as required by subdivision (a) of Section 1569.626, and four hours of which shall be specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696. This training shall be administered on the job, or in a classroom setting, or both, and may include online training. This requirement is not met as evidenced by: Deficient Practice Statement Based on record review, the licensee did not comply with the section cited above in 8 of 10 staff files reviewed. Records did not containt the required number of annual training hours, which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 10/31/2025 Plan of Correction Licensee agrees to ensure all staff complete their required annual training. Licensee shall develop a written plan that describes how facility will track and document staff training hours. Written plan shall be submitted to CCL by 10/31/2025.

Official classification

Type B

Official code

87465(h)(5)

Regulation authority

CCR

What the official deficiency says

(h) The following requirements shall apply to medications which are centrally stored: (5) Each resident's medication shall be stored in its originally received container. No medications shall be transferred between containers. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, the licensee did not comply with the section cited above. Facility is preparing medication in separate cups before assisting residents with medication, resulting in a medication error. This poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 10/31/2025 Plan of Correction Licensee agrees to develop a medication administration procedure that does not include preparing medication in separate containers before assisting the resident with their medication. Written plan shall be submitted to CCL by 10/31/2025.

Official classification

Type A

Official code

87465(c)(2)

Regulation authority

CCR

What the official deficiency says

(c) If the resident's physician has stated in writing that the resident is unable to determine his/her own need for nonprescription PRN medication but can communicate his/her symptoms clearly, facility staff designated by the licensee shall be permitted to assist the resident with self-administration, provided all of the following requirements are met:(2) Once ordered by the physician the medication is given according to the physician's directions. This requirement is not met as evidenced by: Deficient Practice Statement Based on record review, the licensee did not comply with the section cited above. Staff provided the wrong medication to a resident on 3 separate occasions, which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 10/01/2025 Plan of Correction Licensee removed the staff from medication duties and conducted retraining. POC cleared during visit.

Official classification

Type A

Official code

87705(d)

Regulation authority

CCR

What the official deficiency says

87705 Care of Persons with Dementia:(d) The licensee shall ensure that the facility has an auditory device or other staff alert feature to monitor exits on exterior doors and perimeter fence gates accessible to those residents who may be at risk for elopement, as defined in Section 87101, Definitions. This requirement is not met as evidenced by: Based on records reviewed, Licensee did not ensure the front exit door was monitored to ensure the safety of residents. This poses an Immediate Health, Safety or Personal Rights risk to residents in care.

Official plan of correction

Licensee agrees to develop a written plan that outlines how facility will monitor exits to ensure the safety of residents at risk of elopement. Written plan shall be submitted to CCLD by 08/20/2025.

Deadline recorded: Aug 20, 2025. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

1569.157

Regulation authority

HSC

What the official deficiency says

1569.157 Resident-oriented facility council:(c) If a resident council submits written concerns or recommendations, the facility shall respond in writing regarding any action or inaction taken in response to those concerns or recommendations within 14 calendar days. This requirement is not met as evidenced by: Based on records reviewed, Licensee has not responded in writing to the resident council concerns. This poses a potential Health, Safety or Personal Rights risk to persons in care.

Official plan of correction

Licensee agrees to review Health and Safety code 1569.157 and to develop a written plan that outlines how the facility will receive resident council concerns and how they will respond in writing. Written plan shall be submitted to CCLD by 08/29/2025.

Deadline recorded: Aug 29, 2025. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87465(a)(4)

Regulation authority

CCR

What the official deficiency says

87465 Incidental Medical and Dental Care:(4) The licensee shall assist residents with self-administered medications as needed. This requirement is not met as evidenced by: Based on records reviewed, Licensee did not ensure resident received assistance with medication as ordered. This poses an Immediate Health, Safety or Personal Rights risk to residents in care.

Official plan of correction

Licensee updated procedures for entering medications into the system. POC cleared during visit.

Deadline recorded: Aug 20, 2025. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

1569.269(a)(22)

Regulation authority

HSC

What the official deficiency says

(22) To be protected from involuntary transfers, discharges, and evictions in violation of state laws and regulations... This requirement is not met as evidenced by: Based on records reviewed and interviews conducted, Licensee did not accept resident back to the facility when they were discharged This poses an Immediate Health, Safety or Personal Rights risk to persons in care.

Official plan of correction

Licensee agrees to review Health and Safety code 1569.269. Resident returned to the facility. POC cleared during visit.

Deadline recorded: Aug 20, 2025. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

1569.269(a)(24)

Regulation authority

HSC

What the official deficiency says

1569.269 Enumerated rights; severability:(24) To consent to have relatives and other individuals of the resident’s choosing visit during reasonable hours, privately and without prior notice. This requirement is not met as evidenced by: Based on interviews conducted and records reviewed, Licensee issued a visitor policy that prevented residents visiting with individuals of their choosing without prior notice. This poses an immediate Health, Safety or Personal Rights risk to persons in care.

Official plan of correction

Licensee shall review Health and Safety Code section 1569.269 and submit self certification they have reviewed and will abide by the statute. Self Certification shall be submitted to the Department by 07/24/2025. LPA provided copy of Statute for review.

Deadline recorded: Jul 24, 2025. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87303(a)

Regulation authority

CCR

What the official deficiency says

87303 Maintenance and Operation:(a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement is not met as evidenced by: Licensee did not ensure resident pendant alert system was fully operational. This poses a potential Health, Safety or Personal Rights risk to persons in care.

Official plan of correction

Licensee shall develop a written plan to address repair options for call system and methods to ensure residents receive timely assistance from staff. Written plan shall be submitted to CCLD by 07/14/2025.

Deadline recorded: Jul 14, 2025. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87411(a)

Regulation authority

CCR

What the official deficiency says

87411 Personnel Requirements - General:(a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. This requirement is not met as evidenced by: Based on records reviewed, Licensee did not ensure residents received timely assistance as noted in the Resident Hand Book. This poses a potential Health, Safety or Personal Rights risk to persons in care.

Official plan of correction

Licensee shall develop a written plan to address repair options for call system and methods to ensure residents receive timely assistance from staff. Written plan shall be submitted to CCLD by 07/14/2025.

Deadline recorded: Jul 14, 2025. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

1569.652(c)

Regulation authority

HSC

What the official deficiency says

1569.652(c) A refund of any fees paid in advance covering the time after the resident’s personal property has been removed from the facility shall be issued to the individual..., to the resident’s estate, within 15 days after the personal property is removed. This requirement is not met as evidenced by: Based on records reviewed, Licensee did not provide a refund within the 15 day timeframe in regulation. This poses a potential Personal Rights risk to residents in care.

Official plan of correction

Licensee shall issue the refund to responsible party by POC date of 02/28/2025 and send self certification of completed payment to CCL by 02/28/2025.

Deadline recorded: Feb 28, 2025. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87465(a)(4)

Regulation authority

CCR

What the official deficiency says

This requirement is not met as evidenced by: Deficient Practice Statement Based on record review, the licensee did not comply with the section cited above facility did not assist with medications as ordered. This poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 11/06/2024 Plan of Correction Staff was removed from medication duties and retrained in medication procedures. POC cleared during visit.

Official classification

Type B

Official code

87412(c)

Regulation authority

CCR

What the official deficiency says

This requirement is not met as evidenced by: Deficient Practice Statement Based on record review, the licensee did not comply with the section cited above in 7 out of 10 staff files reviewed. Files did not have evidence of completed staff training, which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 11/29/2024 Plan of Correction Licensee shall review staff training procedures and develop a written plan to ensure training is tracked and documented in the personnel files. Written plan to be submitted to CCL by POC date of 11/29/2024.

Official classification

Type A

Official code

87203

Regulation authority

CCR

What the official deficiency says

87203 Fire Safety:All facilities shall be maintained in conformity with the regulations adopted by the State Fire Marshal for the protection of life and property against fire and panic. This requirement is not met as evidenced by: Based on interviews conducted, Licensee did not ensure staff or Fire Department was informed of a new code for an emergency exit. This poses an immediate Safety risk to persons in care.

Official plan of correction

Administrator made Fire Department and staff aware of the new code. POC cleared at time of visit.

Deadline recorded: Oct 8, 2024. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87465(a)(4)

Regulation authority

CCR

What the official deficiency says

87465 Incidental Medical and Dental Care:(4)The licensee shall assist residents with self administered medications as needed. This requirement is not met as evidenced by: Based on records reviewed Facility did not assist with medications as prescribed. This poses an Immediate Health risk to residents. ***An immediate civil penalty is being issued in the amount of $1000 for this repeated violation.

Official plan of correction

Staff responsible was given additional training on medication procedures and facility reviewed their process on entering new orders and verification of exsisting orders. POC cleared during visit.

Deadline recorded: Aug 22, 2024. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87705(k)(6)

Regulation authority

CCR

What the official deficiency says

87705 Care of Persons with Dementia:(6) Without violating Section 87468, Personal Rights, facility staff shall ensure the continued safety of residents if they wander away from the facility.This requirement is not met as evidenced by:Based on records reviewed, 2 residents left the facility without staff knoweldge. This poses an immediate Safety risk to residents in care.

Official plan of correction

A review of the physical alert devices was conducted and care plans were updated. Staff were retrained in the observation requirements for residents. POC cleared during visit.

Deadline recorded: Aug 22, 2024. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87465(a)(4)

Regulation authority

CCR

What the official deficiency says

87465 Incidental Medical and Dental Care:(4) The licensee shall assist residents with self-administered medications as needed. This requirement is not met as evidenced by: Based on records reviewed Facility did not ensure medication was re-ordered in a timely manner. This poses an immediate Health or Safety risk to residents in care.

Official plan of correction

Licensee to develop a written plan to ensure oversight of the re-ordering process for resident medications. Plan to be submitted to CCL by POC date 04/09/2024.

Deadline recorded: Apr 9, 2024. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87307(a)(3)(F)

Regulation authority

CCR

What the official deficiency says

87307 Personal Accommodations and Services:(F) Basic laundry service (washing, drying, and ironing of personal clothing). This requirement is not met as evidenced by: Based on interviews and records reviewed, Licensee did not ensure resident laundry was completed, leaving soiled items in resident rooms for long periods of time. This poses a potential Health risk to residents in care.

Official plan of correction

Licensee to develop a written plan regarding how and when laundry is completed and documented in the building. Written plan to be submitted to CCL by POC date of 4/26/2024.

Deadline recorded: Apr 26, 2024. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87303(a)

Regulation authority

CCR

What the official deficiency says

87303 Maintenance and Operation:(a) The facility shall be clean, safe, sanitary and in good repair at all times. This requirement is not met as evidenced by: Based on interviews conducted, Licensee did not ensure windows in the building were in good repair. Windows in several rooms are not in good repair which causes a potential Health or Safety risk to residents in care. This is a repeat violation, civil penalty of $250.00 is being issued.

Official plan of correction

Licensee is aware of the condition of the windows and has a plan for replacement. Licensee to submit a written plan, including timelines for completion of this project. Plan to be submitted to CCL by POC date 04/26/2024.

Deadline recorded: Apr 26, 2024. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87465(a)(4)

Regulation authority

CCR

What the official deficiency says

87465 Incidental Medical and Dental Care:(4)The licensee shall assist residents with self administered medications as needed. This requirement is not met as evidenced by: Based on records reviewed Facility did not assist with medications as prescribed. Facility did not have medications on hand for resident and did not re-order in a timely manner. This poses an Immediate Health risk to residents.

Official plan of correction

Licensee to provide written procedure that outlines how medications are ordered and how accountability is achieved to ensure medications are available for residents. Written procedure to be submitted to CCL by POC date of 03/11/2024.

Deadline recorded: Mar 11, 2024. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87466

Regulation authority

CCR

What the official deficiency says

87466 Observation of the Resident: The licensee shall ensure that residents are regularly observed for changes in physical functioning...and that appropriate assistance is provided when such observation reveals unmet needs. This requirement is not met as evidenced by: Based on records reviewed, facility did not ensure the care needs of the resident were met. This poses a potential Health risk to residents.

Official plan of correction

Licensee to conduct refresher training on how facility monitors and ensures residents are observed for changes. Self certification of completed training to be submitted to CCL by POC date of 03/29/2024.

Deadline recorded: Mar 29, 2024. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87465(a)(2)

Regulation authority

CCR

What the official deficiency says

87465 Incidental Medical and Dental Care:(2)The licensee shall provide assistance in meeting necessary medical and dental needs. This requirement is not met as evidenced by: Based on records reviewed, Licensee did not ensure wound care was provided to resident. This poses an immediate Health risk to residents in care.

Official plan of correction

Licensee has implemented more frequent meetings with shareholders to ensure communication on the care of residents. POC cleared at time of visit.

Deadline recorded: Jan 24, 2024. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

1569.695(c)

Regulation authority

HSC

What the official deficiency says

(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill. This requirement is not met as evidenced by: Deficient Practice Statement Based on interviews conducted and a review of records, the licensee did not comply with the section cited above. Licensee did not document completed drills, which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 12/04/2023 Plan of Correction Licensee has implemented a new procedure to conduct and document drills monthly. POC cleared at time of visit.

Official classification

Type B

Official code

1569.69(a)(1)

Regulation authority

HSC

What the official deficiency says

(a) Each residential care facility for the elderly licensed under this chapter shall ensure that each employee of the facility who assists residents with the self-administration of medications meets all of the following training requirements: (1) In facilities licensed to provide care for 16 or more persons, the employee shall complete 24 hours of initial training. This training shall consist of 16 hours of hands-on shadowing training, which shall be completed prior to assisting with the self-administration of medications, and 8 hours of other training or instruction, as described in subdivision (f), which shall be completed within the first four weeks of employment. This requirement is not met as evidenced by: Deficient Practice Statement Based on record review, the licensee did not comply with the section cited above in 3 of 5 records reviewed, which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 12/20/2023 Plan of Correction Licensee to submit written plan to address staff training and the documentation of completed training. Written plan to be submitted to CCL by POC date of 12/20/2023.

Official classification

Type A

Official code

87705(c)(4)

Regulation authority

CCR

What the official deficiency says

(4) There is an adequate number of direct care staff to support each resident’s physical, social, emotional, safety and health care needs as identified in his/her current appraisal. This requirement is not met as evidenced by: Based on records reviewed, facility did not ensure staff were present to prevent resident attacking another resident. This poses an immediate Safety risk to residents in care.

Official plan of correction

Facility has updated staff schedules to ensure an adequate number of staff are present to redirect residents with known behaviors. In addition, residents care plan has been updated to address behaviors. POC cleared at time of visit.

Deadline recorded: Sep 27, 2023. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87705(f)(1)

Regulation authority

CCR

What the official deficiency says

(f) The following shall be stored inaccessible to residents with dementia:(1) Knives, matches, firearms, tools and other items that could constitute a danger to the resident(s). This requirement is not met as evidenced by: Based on interviews conducted, resident was in possession of several lighters. This poses an immediate safety risk to residents in care.

Official plan of correction

All lighters have been removed from the residents possession. Facility has implemented a safety plan to ensure lighters are secured. POC Cleared at time of visit.

Deadline recorded: Sep 27, 2023. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87211(a)(1)

Regulation authority

CCR

What the official deficiency says

(1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days...This requirement was not met as evidenced by: Based on records reviewed and interviews conducted, facility did not notify responsible party of several incidents regarding resident. This poses a potential Health, Safety or personal rights risk to residents.

Official plan of correction

Licensee to ensure reporting requirements are followed. Licensee to submit self certification that regulation 87211 has been reviewed and will be followed. Self certification to be submitted to CCL by POC date of 10/20/2023.

Deadline recorded: Oct 20, 2023. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87224(d)(1)(D)

Regulation authority

CCR

What the official deficiency says

The following exact statement as specified in Health and Safety Code Section 1569.683(a)(4):...This requirement is not met as evidenced by: Based on a review of the eviction notice, Licensee did not include the proper language per regulation.

Official plan of correction

Licensee rescinded the eviction. Licensee to review eviction regulation, which was provided by LPA, and send Self Certification they have read and understood. Self Certification to be submitted by POC date 10/20/2023.

Deadline recorded: Oct 20, 2023. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87705(f)(2)

Regulation authority

CCR

What the official deficiency says

87705 Care of Persons with Dementia:(f) The following shall be stored inaccessible to residents with dementia:(2)...and toxic substances such as...cleaning supplies and disinfectants. This requirement is not met as evidenced by:Based on observation, Licensing did not ensure toxic substances were secure and not accessible to residents in care. This poses an immediate Health and Safety risk to residents in care.

Official plan of correction

Licensee to ensure items that could cause harm to residents are secure at all times. Licensee to schedule training regarding Regulation 87705 for all staff working in memory care. Training to be scheduled by POC date of 08/31/2023. Evidence of completed training, with sign in sheets, to be submitted to CCL by POC date of 09/30/2023.

Deadline recorded: Aug 31, 2023. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87411(a)

Regulation authority

CCR

What the official deficiency says

87411 Personnel Requirements - General:(a)Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. This requirement is not met as evidenced by: Based on records reviewed, Licensee did not ensure staff were in numbers sufficient to meet the needs of residents. This poses an immediate Health, Safety or Personal rights risk to residents in care.

Official plan of correction

Licensee to ensure facility has a sufficient number of staff to meet residents needs. Licensee to submit written plan, outlining steps facility is taking to onboard staff. Facility to submit updated LIC500 and staff schedules each month, beginning on POC due date of 08/31/2023.

Deadline recorded: Aug 31, 2023. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87463

Regulation authority

CCR

What the official deficiency says

87463 Reappraisals:(a)The pre-admission appraisal shall be updated, in writing as frequently as necessary to note significant changes and to keep the appraisal accurate. This requirement is not met as evidenced by: Based on record review, Licensee did not update resident appraisal after several assaults on other residents. This poses an immediate Health and Safety risk to residents.

Official plan of correction

Licensee to update residents, R1, Service plan by POC date of 08/30/2023. Licensee to develop a staffing plan to ensure the safety of other residents. Staffing plan to be submitted by 09/06/2023.

Deadline recorded: Aug 30, 2023. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87465(a)(4)

Regulation authority

CCR

What the official deficiency says

87465 Incidental Medical and Dental Care:(a)(4)The licensee shall assist residents with self-administered medications as needed. This requirement is not met as evidenced by: Based on records reviewed, License did not ensure resident received their physician ordered medication when needed for 3 consecutive days. This poses an immediate Health risk to residents in care.

Official plan of correction

Licensee to ensure residents are assisted with medications as needed and staff are fully trained. Licensee to conduct and document training for all medication staff to meet regulation. Training to be scheduled by POC date of 8/30/2023 and training to be completed by 09/30/2023. Evidence of completed training to be submitted upon completion.

Deadline recorded: Aug 30, 2023. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87303(a)

Regulation authority

CCR

What the official deficiency says

87303 Maintenance and Operation:(a)The facility shall be clean, safe, sanitary and in good repair at all times. This requirement is not met as evidenced by: Based on observation, Licensee did not ensure the facility carpets were clean and ceiling was not in good repair. These areas are not related to earthquake damage. This poses a potential Health, Safety or Personal Rights risk to residents in care.

Official plan of correction

Licensee to ensure facility is clean and in good repair. Licensee to submit a written plan to address the carpets cleanliness and to address the flaking ceiling. Plan to be submitted by POC date of 09/13/2023.

Deadline recorded: Sep 13, 2023. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87208(a)

Regulation authority

CCR

What the official deficiency says

(a) Each facility shall have and maintain a current, written definitive plan of operation. This requirement is not met as evidenced by: Based on record review, Licensee did not ensure the facility phone is answered after hours as the resident handbook states. This poses a potential risk to residents in care.

Official plan of correction

Licensee to ensure the facility plan of operation is followed. Licensee will update facilities program plan to address telephone coverage and submit to CCL by POC date of 05/19/2023.

Deadline recorded: May 19, 2023. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87463

Regulation authority

CCR

What the official deficiency says

87463 Reappraisals:(a)The pre-admission appraisal shall be updated, in writing as frequently as necessary to note significant changes and to keep the appraisal accurate. This requirement is not met as evidenced by: Based on record review, Licensee did not update resident appraisal after several injury falls. This poses a potential Health and Safety risk to residents.

Official plan of correction

Licensee to update residents, R1, Service plan, conduct Nurse assessment and update medical assessment. Completed documents to be submitted to CCL by POC date of 03/10/2023.

Deadline recorded: Mar 10, 2023. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87405(a)

Regulation authority

CCR

What the official deficiency says

87405 Administrator - Qualifications and Duties: All facilities shall have a qualified and currently certified administrator...and shall be on the premises a sufficient number of hours to permit adequate attention to the management and administration of the facility. This requirement is not met as evidenced by: Based on interviews conducted, the Administrator is not present at the facility a sufficent number of hours.

Official plan of correction

Licensee to ensure a certified Administrator is present at the facility. Licensee to submit a written plan, including dates and hours, to CCLD outlining how the Licensee will have a Certified and Qualified Administrator present at the facility. Written plan to be submitted to CCL by POC date of 03/09/2023.

Deadline recorded: Mar 9, 2023. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87465(a)(4)

Regulation authority

CCR

What the official deficiency says

87465 Incidental Medical and Dental Care: (4) The licensee shall assist residents with self-administered medications as needed. This requirement is not met as evidenced by: Based on reported incident and record review, faclity staff gave resident wrong medications. This poses a potential risk to residents in care.

Official plan of correction

Facility conducted retraining for involved staff and will conduct refresher training for all medication technicians. Staff training roster to be submitted to CCL by POC date of 03/25/2022.

Deadline recorded: Mar 25, 2022. A deadline is not proof that correction was completed.